Health Improvement Opportuntity Profile

MNT Profile 200 Name Date Nutrition and Eating Assessment V1.0 1. Do you have any dietary preferences (such as eating vegetarian) or some restriction (such as a food allergy) that may limit your food choices?  Yes [please mark list below], if no please skip to question 2. Preferences Pleases indicate the dietary restriction(s) or preference(s) below. Mark all that apply to you.  a - Strict Vegetarian or Vegan – will not eat any animal products such as meat, poultry, seafood, milk (milk products) or eggs.  b - Lacto-ovo vegetarian – will not eat animal product such as meat, poultry or seafood but will eat eggs and milk products such as yoghurt and cheese.  c - Other vegetarian – will not eat most animal products but will eat some.  d - Medical restriction – have a medical condition where my doctor has limited certain foods or has given me a special therapeutic diet.

e - List name of condition(s) here ______ f - Milk intolerance – have a milk allergy and avoid many or all milk products. The following questions are about your eating habits and the specific foods you eat. Before you answer these questions, it may be easier if you first write down everything you ate in the last 24 hours. Or, keep a food diary for three days, recording everything you eat and drink, noting the time of day and the specific amounts. These activities will prepare you to answer the following questions most accurately. 2. On most days, how many meals do you eat? _____ per day 3. How many of those meals are usually prepared by you or someone in your household? _____ per day 4. How many meals per week do you usually eat out? Count meals prepared by a commercial food service, restaurant, deli or fast food provider. _____ per week MNT Nutrition Assessment Survey 5. Breakfast - How often do you eat breakfast? 14. Alcohol - Have you had any alcoholic everyday beverages in the last 6 months? most days  Yes [go to question 15], if no, skip to 16. some days rarely or never 15. How many drinks of beer, wine or Liquor do you regularly have per week? (one drink is 3 to 5 6. Skip meals - How often do you skip a meal? oz. wine, 10 oz wine cooler, 12 oz beer or 1.5 oz everyday liquor) most days _____ drinks per week some days rarely or never 16. Milk preferences - Which statement best 7. Night eating - How often do you eat a meal or describes the fat content of milk you would snack less than 2 hours before bedtime? choose to drink? everyday Only regular whole milk (about 4% fat) most days Both regular whole milk and low fat milk some days Only low-fat milk (1 to 2 % fat) rarely or never Both low-fat and non-fat milk Only non-fat milk (0.5% fat) 8. Appetite – How do you rate your appetite or Do not drink dairy milk desire for food? very good good 17. Fat preferences - When choosing foods for your meal, do you usually select, high-fat or not always good low-fat foods? After reviewing the examples, poor most of the time select the most appropriate response. 9. Satisfied - How often do you stop eating after you feel you have eaten enough? High-fat examples: hamburgers, sausages, always luncheon meat, marbled beef, sour cream, most of the time cheese, eggs, butter, pastry, ice cream, full-fat some of the time dairy products, chocolate, fried foods and many rarely or never fast foods 10. Binging, is to lose control by eating a large Low-fat examples: lean meats, skinless poultry, amount of food over a short period of time. Do fish, low-fat dairy products, fruit desserts, gelatin, you ever binge? vegetables, pasta, and legumes (peas and  Yes, if no, skip to question 12. beans) 11. How many times per week? choose high-fat foods nearly all the time _____ per week choose high-fat foods most of the time choose both high and low-fat foods equally as 12. Water - Think about what you drink all during often the day. How many cups (8 oz cup) of water or choose low-fat foods most of the time other non-caffienated beverages such as juice do choose low-fat foods all the time you have on most days (do not count tea, coffee, beer or other alcoholic beverages)? _____ per day 13. How many caffeinated beverages do you drink each day? Please include regular tea, coffee, espressos, lattes, or caffeinated soft drinks. _____ per day

Copyright © 2002 by Gobble, Shults & Associates, Inc. Page 2 MNT Nutrition Assessment Survey 18. Added salt - How often do you add salt to your food? Physical Activity and Other not at all occasionally (2 – 3 times per week) 1. Judge your current activity level. Think about how active you are on most days. Consider the Moderately (one meal per day) following definitions. Quite often (nearly every meal) Majority of the time (on most everything) Rest: Sleeping or reclining. 19. Salty food - How often do you eat salty foods Very light activity: Seated at a desk or (such as soy sauce, pickles, canned meats, standing activities, painting trades, driving, laboratory work, typing, sewing, ironing, salted nuts or potato or corn chips)? cooking, playing cards, playing a musical not at all instrument. occasionally Light activity: Walking on a level surface at Moderately 2.5 to 3 mp, garage work, electrical trades, Quite often carpentry, restaurant trades, house cleaning, Majority of the time childcare, golf, sailing, or table tennis. 20. Fiber preferences How often do you choose Moderate activity: Walking 3.5 to 4 mph, to eat high-fiber foods such as whole wheat weeding and hoeing, carrying a load, cycling, bread or pasta, high-fiber breakfast cereal and tennis, or dancing. brown rice? Heavy activity: Walking with a load uphill, tree felling, heavy manual digging, field rarely or never hockey, climbing, playing soccer or football. occasionally sometimes Select the choice below that best describes your majority of the time activity during a typical day? always  Very Light: 10 hours of rest and 14 hours of 21. Supplements - Do you take vitamin pills very light activity. such as vitamin C, calcium, or other nutrient  Light: 10 hours of rest and 14 hours of only light supplements on a typical day? activity.  Moderately active: 10 hours of rest and 14 hours of  Yes, if no, skip to the next section. light and/or moderate activity List supplements – If you are taking  Very active: 10 of rest and 14 hours of moderate supplements, list them below. and heavy activity. ______ Vigorously active: 10 hours of rest and 14 hours of ______heavy activity. ______2. - How much time do you spend in moderate ______(walking, easy cycling, swimming, active ______gardening, gym workouts) or vigorous (jogging, ______running, active sports, heavy labor) physical activity each week?  I am not physically active on a regular basis.  I do moderate activities for less than 30 minutes at a time, on some (1-3) days of the week.  I do moderate activities for less than 30 minutes at a time, on most (4-7) days of the week.  I do moderate activities for at least 30 minutes at a time, on some (1-3) days of the week.  I do moderate activities for at least 30 minutes at a time, on most (4-7) days of the week.

3. Exercise restrictions – Has a doctor every told you to restrict or limit physical activity or exercise?  Yes, if no, skip to next question. 4. Smoking – Do you smoke cigarettes every day?  yes [go to question 5], if no, skip to 6.

5. How many cigarettes do you smoke a day?

 less than one pack a day  about one pack a day  more than one pack a day

6. Other tobacco – Do you use other tobacco?  Yes; if no, skip to next question

Readiness to Change

7. Good nutrition and dietary habits include eating a balanced diet from a variety of wholesome foods. This involves eating appropriate amounts from each food group and avoiding excess fat, alcohol or calories. Mark the response below that best describes your current intentions to adopt good nutrition and dietary habits.  I am not planning to adopt any new nutrition or dietary habits this year.  I'm planning to start making improvements in my nutrition and dietary habits in the next six months.  I'm planning to start making improvements in my nutrition and dietary habits in the next 30 days.  I've adopted good nutrition and dietary habits and maintained them for less than 6 months.  I've adopted good nutrition and dietary habits and maintained them for more than 6 months.